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9. Shoulder and Elbow MCQs

Practice Set 152 of 197

This practice set contains high-yield board review questions covering key concepts in 9. Shoulder and Elbow. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 3021

Topic: Elbow & Forearm

A 38-year-old bodybuilder sustains a distal biceps tendon rupture and undergoes a two-incision (Mayo) repair. Postoperatively, he presents with an inability to extend his fingers and thumb, though wrist extension is preserved but deviates radially. Sensation is intact. Which technical error most likely caused this complication?

. Over-retraction of the medial antebrachial cutaneous nerve during the anterior approach
. Entrapment of the superficial radial nerve in the biceps tendon tunnel
. Vigorous retraction around the radial neck during the posterolateral exposure
. Direct transection of the anterior interosseous nerve while exposing the radial tuberosity
. Compression of the median nerve by the bicipital aponeurosis repair

Correct Answer & Explanation

. Vigorous retraction around the radial neck during the posterolateral exposure

Explanation

The patient has a posterior interosseous nerve (PIN) palsy, evidenced by the loss of finger/thumb extension and radial deviation with wrist extension (ECRL is intact via the radial nerve proper, but ECU is out). In the two-incision distal biceps repair, the PIN is at highest risk of injury during the posterolateral approach if retractors are placed too vigorously around the radial neck. Supinating the forearm moves the PIN further away from the surgical field during this step.

Question 3022

Topic: Elbow & Forearm

A 45-year-old man receives a radial head replacement for a highly comminuted radial head fracture. Two years postoperatively, he complains of progressive lateral elbow pain and stiffness. Radiographs demonstrate widening of the lateral ulnohumeral joint space and erosive changes of the capitellum. What is the most likely cause of these findings?

. Overstuffing the radiocapitellar joint with a prosthetic implant that is too thick
. Undersizing the radial head implant, leading to valgus instability
. A latent subclinical infection (e.g., Cutibacterium acnes)
. Unrecognized disruption of the medial collateral ligament (MCL)
. Proximal radioulnar impingement due to an elongated implant stem

Correct Answer & Explanation

. Overstuffing the radiocapitellar joint with a prosthetic implant that is too thick

Explanation

Using a radial head implant that is too thick 'overstuffs' the radiocapitellar joint. This causes increased contact pressures on the capitellum, leading to early cartilage wear, osteonecrosis, or capitellar erosion. It also artificially widens the lateral ulnohumeral joint space on radiographs and restricts elbow flexion and forearm rotation.

Question 3023

Topic: Elbow & Forearm

A 35-year-old female falls on an outstretched hand and sustains an isolated capitellar fracture.

According to the Dubberley classification of capitellum fractures, what finding distinguishes a Type 3 fracture from a Type 1 or 2, and what is its primary surgical implication?

. Involvement of the medial trochlea; requires a dual-incision approach
. Comminution of the posterior aspect of the capitellum; requires bone grafting or a posterior buttress plate
. Anterior articular cartilage impaction; requires an osteochondral autograft transfer
. Associated lateral epicondyle fracture; requires concurrent LUCL reconstruction
. Extension into the radiocapitellar joint space; mandates radial head excision

Correct Answer & Explanation

. Comminution of the posterior aspect of the capitellum; requires bone grafting or a posterior buttress plate

Explanation

The Dubberley classification for capitellum and trochlea fractures is based on the presence of posterior comminution. Type 1 involves the capitellum, Type 2 involves the capitellum and trochlea as a single piece. A Type 3 fracture is distinguished by the presence of posterior comminution, which destroys the posterior buttress. This implies that simple anterior-to-posterior screw fixation will fail due to lack of posterior support, often necessitating bone grafting or posterior buttress plating.

Question 3024

Topic: 9. Shoulder and Elbow

A 12-year-old competitive baseball pitcher presents with medial elbow pain that worsens during pitching. Radiographs show widening and irregularity of the medial epicondyle apophysis. What is the primary pathophysiologic mechanism causing 'Little League Elbow' in this patient population?

. Excessive compressive forces across the radiocapitellar joint during the late cocking phase
. Repetitive valgus stress generating high tension across the medial epicondyle during the acceleration phase
. Varus overload on the medial collateral ligament during the deceleration phase
. Traction apophysitis from the triceps tendon during follow-through
. Direct friction of the ulnar nerve against a hypertrophied Osborne's ligament

Correct Answer & Explanation

. Repetitive valgus stress generating high tension across the medial epicondyle during the acceleration phase

Explanation

'Little League Elbow' represents a spectrum of medial elbow injuries in overhead throwers, most commonly medial epicondyle apophysitis in skeletally immature patients. The pitching motion, particularly during the late cocking and early acceleration phases, generates tremendous valgus stress on the elbow. This results in tension-overload on the medial structures (causing apophysitis or avulsion) and compression on the lateral structures (radiocapitellar joint, potentially leading to osteochondritis dissecans of the capitellum).

Question 3025

Topic: Shoulder Pathology

A 25-year-old female presents with severe, painful crepitus and snapping at the superomedial border of her scapula during active arm elevation. Extensive non-operative management has failed to provide relief. If an arthroscopic excision of the superomedial angle of the scapula is performed, which muscle's insertion must be carefully elevated and subsequently securely repaired?

. Rhomboid major
. Levator scapulae
. Serratus anterior
. Supraspinatus
. Trapezius

Correct Answer & Explanation

. Levator scapulae

Explanation

Snapping scapula syndrome is often caused by friction between the superomedial angle of the scapula and the underlying rib cage. Surgical treatment involves resecting the superomedial angle of the scapula and bursectomy. The levator scapulae muscle inserts onto the superomedial angle of the scapula. During the resection, this insertion is elevated and must be repaired back to the scapular border to prevent functional deficits.

Question 3026

Topic: 9. Shoulder and Elbow

A 30-year-old male with a devastating global brachial plexus injury (C5, C6, C7 root avulsions) is undergoing a shoulder arthrodesis to stabilize his shoulder and allow better positioning for his remaining hand/elbow function. According to current biomechanical and functional literature, what is the optimal position for glenohumeral arthrodesis?

. 45° abduction, 45° forward flexion, 45° internal rotation
. 30° abduction, 30° forward flexion, 30° internal rotation
. 15° abduction, 15° forward flexion, 0° internal rotation
. 60° abduction, 30° forward flexion, 0° internal rotation
. 0° abduction, 45° forward flexion, 45° external rotation

Correct Answer & Explanation

. 30° abduction, 30° forward flexion, 30° internal rotation

Explanation

The optimal position for shoulder arthrodesis is a classic 'Rule of 30s': approximately 30° of abduction, 30° of forward flexion, and 30° of internal rotation. This position allows the hand to reach the mouth (crucial for feeding and hygiene) and minimizes winging of the scapula while keeping the arm close enough to the body to pass through doorways.

Question 3027

Topic: 9. Shoulder and Elbow

A 12-year-old boy presents after falling onto an outstretched hand. He was found to have an elbow dislocation, which was closed reduced in the emergency department. Post-reduction, the elbow joint appears congruent, but the medial epicondyle is no longer visible in its anatomic position. A radiograph reveals a bone fragment within the joint space.

Which of the following is the most appropriate management for this patient?

. Long-arm cast immobilization with the elbow flexed at 90 degrees
. Repeated closed reduction maneuvers under conscious sedation
. Open reduction and internal fixation of the incarcerated fragment
. Excision of the fragment with primary repair of the medial collateral ligament
. Observation with early active range of motion at 1 week

Correct Answer & Explanation

. Open reduction and internal fixation of the incarcerated fragment

Explanation

An incarcerated medial epicondyle fragment within the elbow joint after reduction of a dislocation is an absolute indication for operative intervention. The fragment is typically tethered by the flexor-pronator mass and the medial collateral ligament. Attempting to mobilize the elbow with an intra-articular fragment will lead to rapid cartilage destruction and mechanical block. Open reduction and internal fixation (ORIF) allows for joint clearance, anatomic restoration of the flexor-pronator origin, and stabilization of the MCL.

Question 3028

Topic: Elbow & Forearm

During open reduction and internal fixation of a highly comminuted capitellum fracture, excessive posterior soft tissue stripping is performed. The patient subsequently develops avascular necrosis (AVN) of the capitellum. Which of the following best describes the anatomical basis for this complication?

. Disruption of the radial recurrent artery traversing the anterior capsule
. Disruption of the middle collateral artery traveling with the ulnar nerve
. Disruption of the end-vessels entering the capitellum via posterior capsular attachments
. Disruption of the interosseous recurrent artery at the lateral epicondyle
. Disruption of the superior ulnar collateral artery

Correct Answer & Explanation

. Disruption of the end-vessels entering the capitellum via posterior capsular attachments

Explanation

The capitellum is primarily supplied by penetrating end-vessels that enter the bone posteriorly through the capsular attachments. Because the articular surface covers the anterior, inferior, and lateral aspects of the capitellum, there is no direct anterior vascular supply. Aggressive posterior dissection or stripping of the posterior soft tissues during surgical approaches (such as an extended lateral approach) significantly increases the risk of avascular necrosis.

Question 3029

Topic: Shoulder Pathology

A 28-year-old manual laborer complains of a painful grating sensation and audible popping at the superomedial border of his right scapula with overhead activities. Nonoperative management, including targeted periscapular strengthening and corticosteroid injections, has failed after 6 months. If surgical excision of the inflamed bursae is performed, which of the following bursae are specifically targeted in this region?

. Subscapular and subcoracoid bursae
. Supraserratus and infraserratus bursae
. Trapezoid and subacromial bursae
. Bicipital and coracobrachial bursae
. Luschka's bursa and subdeltoid bursa

Correct Answer & Explanation

. Supraserratus and infraserratus bursae

Explanation

Snapping scapula syndrome (scapulothoracic crepitus) often involves inflammation of the bursae located at the superomedial angle of the scapula. The two primary bursae in this specific anatomic location that become pathologic and require excision in refractory soft-tissue cases are the supraserratus bursa (located between the subscapularis and serratus anterior) and the infraserratus bursa (located between the serratus anterior and the chest wall).

Question 3030

Topic: Elbow & Forearm

During the surgical management of a 'Terrible Triad' injury of the elbow, the lateral ulnar collateral ligament (LUCL) is repaired to the humerus using suture anchors.

To ensure isometric function of the LUCL throughout the arc of elbow flexion and extension, where must the humeral anchor be placed?

. At the proximal pole of the lateral epicondyle
. At the exact center of rotation of the capitellum
. Anterior and superior to the capitellar axis of rotation
. Directly on the supinator crest
. Distal to the annular ligament reflection

Correct Answer & Explanation

. At the exact center of rotation of the capitellum

Explanation

The isometric point for the origin of the lateral collateral ligament complex (specifically the LUCL) is located at the center of the axis of rotation of the capitellum on the lateral epicondyle. Repairing the ligament at this exact center of rotation ensures that the ligament maintains consistent tension throughout the entire arc of elbow flexion and extension, minimizing the risk of recurrent instability or severe stiffness.

Question 3031

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate baseball pitcher is undergoing evaluation for medial elbow pain.

The examiner places the patient's shoulder in 90 degrees of abduction and external rotation, rapidly extends the elbow from full flexion to 30 degrees, and applies a valgus torque. The patient reports a sharp pain specifically between 120 and 70 degrees of elbow flexion. This clinical test (Moving Valgus Stress Test) evaluates the integrity of which specific structure?

. Posterior bundle of the ulnar collateral ligament
. Anterior bundle of the ulnar collateral ligament
. Transverse ligament of Cooper
. Flexor carpi ulnaris origin
. Ulnar nerve at the cubital tunnel

Correct Answer & Explanation

. Anterior bundle of the ulnar collateral ligament

Explanation

The Moving Valgus Stress Test is highly sensitive and specific for insufficiency of the anterior bundle of the ulnar collateral ligament (UCL), which is the primary restraint to valgus stress at the elbow. A positive test is indicated by medial elbow pain reproduced at the shear range of 120 to 70 degrees of elbow flexion as the elbow is rapidly extended with applied valgus torque.

Question 3032

Topic: Elbow & Forearm

A 45-year-old mechanic presents with an inability to actively extend his thumb and the fingers at the metacarpophalangeal (MCP) joints.

Wrist extension is preserved but distinctly deviates radially. Sensation in the hand and forearm is entirely normal. Which of the following structures is the most frequent site of compression causing this exact clinical picture?

. The tendinous margin of the extensor carpi radialis brevis (ECRB)
. The arcade of Struthers
. The proximal fibrous edge of the superficial head of the supinator (Arcade of Frohse)
. The distal border of the pronator teres
. The leash of Henry

Correct Answer & Explanation

. The proximal fibrous edge of the superficial head of the supinator (Arcade of Frohse)

Explanation

This is a classic presentation of Posterior Interosseous Nerve (PIN) syndrome. The PIN is a purely motor nerve after it branches from the radial nerve proper. Compression classically occurs at the Arcade of Frohse (proximal edge of the superficial head of the supinator). It leads to paralysis of the EDC, EIP, EDM, EPL, EPB, and APL. Wrist extension is preserved (but deviates radially) because the extensor carpi radialis longus (ECRL) and brevis (ECRB) are typically innervated by the radial nerve proximal to the bifurcation or arcade.

Question 3033

Topic: 9. Shoulder and Elbow

A 6-year-old girl falls off monkey bars and presents with elbow swelling and forearm deformity. Radiographs demonstrate an anterior dislocation of the radial head and a fracture of the ulnar diaphysis with anterior apex angulation. Which of the following is the standard initial treatment principle for achieving and maintaining reduction of the radial head in this specific fracture-dislocation (Bado Type I)?

. Open reduction of the radial head followed by annular ligament reconstruction
. Anatomic closed or open reduction of the ulna fracture length and alignment
. Radial head excision to prevent chronic radiocapitellar arthritis
. Immobilization of the forearm in maximum pronation and 45 degrees of elbow flexion
. Immediate application of a dynamic external fixator bridging the elbow

Correct Answer & Explanation

. Anatomic closed or open reduction of the ulna fracture length and alignment

Explanation

This describes a Bado Type I Monteggia fracture-dislocation (anterior dislocation of radial head, anterior angulation of ulnar shaft). The cardinal principle of treating Monteggia fractures is that anatomic restoration of ulnar length and alignment will almost always spontaneously reduce the radial head. If the radial head remains dislocated after anatomic ulnar fixation, one must suspect soft-tissue interposition (such as the annular ligament or joint capsule) requiring open reduction.

Question 3034

Topic: 9. Shoulder and Elbow

A 35-year-old male suffered a severe traumatic brain injury and an ipsilateral elbow fracture-dislocation 8 months ago.

He now presents with a rigid elbow contracture secondary to massive heterotopic ossification (HO). Before proceeding with surgical excision of the HO and capsular release, which of the following criteria is considered the most reliable indicator that the HO is "mature" enough to minimize the risk of massive postoperative recurrence?

. Six weeks have elapsed since the original injury
. Serum alkaline phosphatase levels remain severely elevated
. Bone scintigraphy shows intense, actively increasing localized uptake
. Radiographs display distinct, sharply demarcated trabecular bone margins without fluffy edges
. The patient has regained full neurologic function from the traumatic brain injury

Correct Answer & Explanation

. Radiographs display distinct, sharply demarcated trabecular bone margins without fluffy edges

Explanation

Timing of heterotopic ossification (HO) excision is critical to prevent recurrence. Historically, surgeons waited for normalization of serum alkaline phosphatase or bone scan activity, but recent literature confirms that the most reliable practical indicator for maturation is radiographic appearance: the HO should have sharp, distinct cortical margins and a well-defined trabecular pattern (typically takes 6 months). Fluffy or cloud-like margins indicate active, immature bone formation.

Question 3035

Topic: Elbow & Forearm

A 45-year-old male weightlifter sustains an acute distal biceps tendon rupture. He undergoes operative repair via a single-incision anterior approach using cortical button fixation.

Postoperatively, he complains of an area of numbness and tingling extending down the radial (lateral) aspect of his forearm. Which nerve is most likely injured, and what specific surgical maneuver places it at highest risk?

. Posterior interosseous nerve; passing the drill pin through the dorsal cortex of the radius
. Lateral antebrachial cutaneous nerve; aggressive lateral retraction of the skin and subcutaneous tissue
. Superficial radial nerve; dissecting deep to the brachioradialis muscle belly
. Median nerve; placing retractors medially against the pronator teres
. Medial antebrachial cutaneous nerve; incision over the medial bicipital groove

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve; aggressive lateral retraction of the skin and subcutaneous tissue

Explanation

The Lateral Antebrachial Cutaneous Nerve (LABCN), which is the terminal sensory branch of the musculocutaneous nerve, exits lateral to the biceps tendon in the distal arm. It is highly susceptible to neuropraxia during a single-incision anterior approach to the distal biceps due to aggressive lateral retraction of the superficial soft tissues. It provides sensation to the radial/lateral aspect of the forearm.

Question 3036

Topic: 9. Shoulder and Elbow

A 40-year-old male sustains a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the generally recommended sequence of repair to restore elbow stability?

. Coronoid, LCL complex, radial head, MCL if needed
. Radial head, LCL complex, coronoid, MCL if needed
. Coronoid, radial head, LCL complex, MCL if needed
. LCL complex, radial head, coronoid, MCL if needed
. MCL, coronoid, radial head, LCL complex

Correct Answer & Explanation

. Coronoid, LCL complex, radial head, MCL if needed

Explanation

The standard surgical algorithm for a terrible triad injury begins deep and moves superficial: fixation or replacement of the coronoid first, followed by the radial head, and then repair of the lateral collateral ligament (LCL) complex. The medial collateral ligament (MCL) is only repaired if the elbow remains grossly unstable after these initial steps.

Question 3037

Topic: Shoulder Pathology

A 28-year-old mechanic complains of right shoulder pain and weakness 4 months after a radical neck dissection. Examination reveals lateral winging of the scapula, with the scapula translated laterally and rotated downward. Which muscle-nerve combination is deficient, and what is the preferred salvage tendon transfer?

. Serratus anterior / Long thoracic nerve / Pectoralis major transfer
. Trapezius / Spinal accessory nerve / Eden-Lange procedure
. Rhomboids / Dorsal scapular nerve / Split pectoralis major transfer
. Serratus anterior / Spinal accessory nerve / Eden-Lange procedure
. Trapezius / Long thoracic nerve / Pectoralis minor transfer

Correct Answer & Explanation

. Trapezius / Spinal accessory nerve / Eden-Lange procedure

Explanation

Lateral winging with a downwardly rotated scapula following neck surgery suggests trapezius palsy secondary to a spinal accessory nerve injury. The Eden-Lange procedure, which transfers the levator scapulae and rhomboids, is the preferred reconstructive option for this condition.

Question 3038

Topic: Shoulder Arthroplasty & Arthritis

In planning a reverse total shoulder arthroplasty (rTSA), the surgeon decides to use a lateralized glenosphere rather than a standard medialized Grammont design. What is the primary biomechanical advantage of lateralizing the center of rotation on the glenoid side?

. Increases the deltoid moment arm
. Decreases the risk of inferior scapular notching
. Reduces shear forces on the glenoid baseplate
. Maximizes the tension of the triceps
. Improves internal rotation strictly by subscapularis tensioning

Correct Answer & Explanation

. Reduces shear forces on the glenoid baseplate

Explanation

A lateralized glenosphere moves the humerus laterally away from the scapular neck, significantly decreasing the risk of inferior scapular notching and improving external rotation by tensioning the remaining posterior rotator cuff. However, it increases shear forces at the glenoid baseplate interface.

Question 3039

Topic: Elbow & Forearm
A 35-year-old female falls on an outstretched hand and sustains a coronal shear fracture of the distal humerus involving the capitellum and extending medially to include the lateral ridge of the trochlea. According to the Bryan and Morrey classification, what type of fracture is this?
. Type I (Hahn-Steinthal)
. Type II (Kocher-Lorenz)
. Type III (Broberg-Morrey)
. Type IV (McKee modification)
. Type V (Dubberley modification)

Correct Answer & Explanation

. Type IV (McKee modification)

Explanation

A Type IV coronal shear fracture, added by McKee to the Bryan and Morrey classification, involves the capitellum and extends medially to include the lateral ridge of the trochlea (the capitellotrochlear shear fracture). Type I involves primarily the capitellum with significant subchondral bone, whereas Type II is mostly an articular cartilage shell.

Question 3040

Topic: Elbow & Forearm

A surgeon is performing a two-incision distal biceps repair (modified Boyd-Anderson approach). To minimize the risk of proximal radioulnar synostosis, which technical step is most critical during the procedure?

. Splitting the supinator muscle blindly
. Preserving the ulnar bursa
. Exposing the radial tuberosity through the extensor carpi ulnaris
. Avoiding subperiosteal dissection and exposure of the ulna
. Using a cortical button rather than suture anchors

Correct Answer & Explanation

. Avoiding subperiosteal dissection and exposure of the ulna

Explanation

In a two-incision distal biceps repair, heterotopic ossification and proximal radioulnar synostosis are major risks. This complication is minimized by strictly avoiding any exposure or subperiosteal elevation of the ulna when creating the posterolateral window.

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